VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Poet's Walk of Leesburg
102 Desmond Plaza
Leesburg, VA 20175
(571) 224-9516

Current Inspector: Jacquelyn Kabiri (703) 397-3017

Inspection Date: Jan. 31, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDINGS AND GROUND

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: LI entered the facility at 10:10 am on 1/31/2023 and exited the facility at 3:00 pm on 1/31/2023. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 1/23/2023 regarding allegations in the area(s) of resident care and buildings and grounds. Number of residents present at the facility at the beginning of the inspection: 44 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: LI observed the living conditions in the resident?s room and observed the conditions in other areas of the facility. LI reviewed monthly weights for the resident. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. However, violation(s) not related to the complaint, but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-440-A
Complaint related:	No
Description:	Based on a review of records, the facility failed to ensure that the Uniform Assessment Instrument (UAI) for all residents of assisted living facilities be completed at least annually. Evidence: According to the record of Resident #1, the last UAI was completed on 11/5/2021.
Plan of Correction:	An audit of all Resident UAI?s was conducted on 2/1/2023 and 2/2/2023 by the Director of Nursing (DON). As of 2/8/2023, all Resident UAI?s are now in compliance with Standard Number 440-A. A tracking spreadsheet has been developed and implemented as of 2/8/2023, to alert nursing staff to the annual due date for each UAI. Person(s) Responsible: Executive Director, DON, and Assistant Director of Nursing.